Spa Waiver Form V2

Woodstock Inn & Resort

Spa Waiver Form

Personal Information

First & Last Name ______________________________________________

Address _______________________________________________________

Birthday _______________________________________________________

Phone (______) - ______ - ________

E-mail __________________________________________________________

COVID-19

I certify that I have reviewed the State of Vermont out-of-state traveler guidelines and travel map and

comply with current health and safety requirements for traveling to, from, and within the State of

Vermont. I further certify that I understand all travelers should stay home if ill (with any symptoms);

maintain physical distance of at least 6’ from anyone outside their household; wear a cloth mask when

in public spaces; and wash or sanitize hands often.

Treatment Details

Please indicate any areas you would like the therapist to focus on during your massage.

___________________________________________________________________________________________________

Anything else you would like your therapist to know regarding any recent injuries?

___________________________________________________________________________________________________

Please list any allergies or skin sensitivities.

___________________________________________________________________________________________________

If you are pregnant, # of weeks? ____________________________________________________________________

Please list any medications.

___________________________________________________________________________________________________

If receiving a facial, please list date and use of Botox or peel.

___________________________________________________________________________________________________

In the event you experience any pain or discomfort during your treatment, please let your provider know

immediately.

Any illicit or sexually suggestive remarks or advances may be considered sexual harassment and will

result in the immediate termination of the session.

Because massage, bodywork, or facials should not be performed under certain medical conditions, I

affirm that I have stated all my known medical conditions below. I agree to keep the practitioner

updated as to any changes in my medical profile and understand that there shall be no liability on

the practitioner’s part should I fail to do so.

Please list relevant medical conditions.

___________________________________________________________________________________________________

Would you like to receive e-mail promotions? Yes No

How did you hear about us? Hotel Local B&B Friend Other ________________________

Waiver & Release For Spa

Please take a moment to carefully read the following information and sign where indicated.

In consideration of my participation in Spa Services (massage, manicure, pedicure, depilation, facials, etc.)

at The Spa (the “Facility”) I hereby release, discharge and covenant not to sue The Spa at the Woodstock

Inn & Resort. Including their respective directors, officers, employees, agents representatives, insurers,

clients, successors, assigns, and any property owners, (“Released Parties”) and further release from

liability the released Parties from any and all claims, losses damages, or liability, INCLUDING LOSSES

DUE TO THE NEGLIGENCE OF RELEASED PARTIES WHEN PERFORMING ANY SPA SERVICES,

(“Losses”) resulting on personal injury, accidents or illnesses (including death), and property loss, including

theft, arising from participation in the Spa Services or using the Facility. Released Parties are not liable for

any theft, or loss of personal property, including jewelry or other personal items. In no event shall the

Released Parties be liable for property exceeding $1,000 and will only be liable for that amount if the item

was registered with the Facility and the loss was caused solely by the fault of the Related Parties.

I understand that the staff does not diagnose illness or prescribe medical treatments or pharmaceuticals

and that services rendered by the staff are not medical in nature and are not a substitute for diagnosis and

treatment by a licensed medical professional. I have consulted a physician regarding participation in the

Spa Services and I shall update my service provider with any changes in my health, and my services

provider shall not be liable should I fail to do so.

I hereby understand that my participation in the Spa Services shall carry certain inherent risks that cannot

be eliminated regardless of care taken to avoid injuries. I HEREBY STATE THAT MY PARTICIPATION IN

THE SPA SERVICES IS VOLUNTARY, AND I ASSUME ALL RISK. Risk include, but are not limited to:

MINOR RISKS: minor injuries such as bruises, improper product application, scratches, skin irritation,

allergic reactions, and minor bleeding.

MAJOR RISKS: such as eye injury, loss of sight, infection, permanent scarring, dermatological skin

reactions, heart attacks, allergic reactions, concussions, personal injury and catastrophic injuries such as

paralysis or death.

By entering your name below and submitting this form you certify to have read and understand this

questionnaire.

I have hereby read and understand this waiver, and I release the Released Parties from any and all

Liability INCLUDING FOR NEGLIGENCE, past, present and future relating to Spa Services at the

Facility. I am giving up substantial rights, including rights to sue, and I acknowledge that I am signing

this waiver voluntarily.

Client Name _____________________________________________________________________

Parent/Guardian Name (If applicable) ______________________________________________

Date _____________________________________________________________________________